Please complete all fields below.

Are you prevented from lawfully becoming employed in this Country because of VISA or IMMIGRATION STATUS?

YesNo

Do you have a valid Driver's License?

YesNo

What is your means of transportation to work?

Driver's License #:

State of issue:

Select 1:OperatorCommercial(CDL)

Expiration Date:

Have you had any accidents during the past three years?YesNo

How many?

Have you been convicted of a felony or misdemeanor within the last 5 years?YesNo

Describe:

***You will NOT be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied.

Employment Desired

Position

Date you can start

Salary Desired

Are you employed now?YesNo

If so, may be contact your present employer?

Have you applied to this company before?YesNo

Where?

When?

Referred By

Have you ever operated any heavy equipment?YesNo

Please describe equipment you are familiar with and have operated

Former Employers (LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST)

Date(Year)

Name & Address

Salary

Position

Reason for leaving

Date(Year)

Name & Address

Salary

Position

Reason for leaving

Date(Year)

Name & Address

Salary

Position

Reason for leaving

References: (Give the names of three persons NOT related to you, whom you have known at least one year)

Name

Address

Business

Years Known

Name

Address

Business

Years Known

Name

Address

Business

Years Known

"I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE, AND I UNDERSTAND THAT IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF I AM EMPLOYED. MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME.

IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM BETTS ENVIRONMENTAL RULES AND REGULATIONS AND I AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE AT ANY TIME AT EITHER MY OR THE COMPANY’S OPTION I ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS OF MY EMPLOYMENT MAY BE CHANGED WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE AT ANY TIME BY THE COMPANY I UNDERSTAND THAT NO BETTS ENVIRONMENTAL REPRESENTATIVE OTHER THAN IT’S PRESIDENT AND THEN ONLY WHEN IN WRONG AND SIGNED BY THE PRESIDENT HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING."